CROSSROADS ANIMAL HOSPITAL NEW CLIENT REGISTRATION FORM

OWNER’S NAME__________________________________________________________________________________________

ADDRESS __________________________________________________ CITY _________________________ ZIP____________

PHONE HOME (       )_____________________ CELL (       )_____________________ WORK (       )______________________

E-MAIL ADDRESS (THIS WILL BE KEPT CONFIDENTIAL) __________________________________________________________

EMPLOYER’S NAME____________________________ SPOUSE OR SIGNIFICANT OTHER________________________________

SPOUSE’S EMPLOYER______________________ CELL (       )____________________ WORK (       )______________________

CHILDREN'S NAMES_______________________________________________________________________________________

PET’S NAME_________________________________________________ DATE OF BIRTH_______________________________

[   ]CAT   [   ]DOG  [   ] BIRD  [   ]OTHER    TYPE_________________ [  ] MALE  [  ] FEMALE [  ] NEUTERED [  ] UNNEUTERED 

BREED__________________________________________________ COLOR__________________________________________

ANY OTHER PETS AT HOME ?__________WHAT TYPE?___________________________________________________________

PREVIOUS VETERINARIAN ____________________________________________MAY WE CALL FOR RECORDS?_____________

PREVIOUS MEDICAL CONDITIONS OR SURGERIES_______________________________________________________________

________________________________________________________________________________________________________

LIST ANY MEDICATIONS USED INCLUDING OVER-THE-COUNTER __________________________________________________

________________________________________________________________________________________________________

ANY HISTORY OF VACCINE REACTION? ______________  ALLERGIES? _____________________________________________

WHAT IS YOUR PET'S DIET (INCLUDING TREATS AND TABLE SCRAPS)?_____________________________________________

________________________________________________________________________________________________________

DO YOU HAVE PET INSURANCE?_______ IF YES, WHO IS YOUR PROVIDER?_________________________________________

IF NO, WOULD YOU LIKE INFORMATION ON PET INSURANCE?____________________________________________________

HOW DID YOU HEAR ABOUT OUR HOSPITAL? __________________________________________________________________

IF PERSONAL REFERENCE, WHOM MAY WE THANK? _____________________________________________________________

THE PERSONAL INFORMATION YOU HAVE PROVIDED WILL NOT BE SHARED WITH ANY THIRD PARTIES.

*PAYMENT VIA CASH, CHECK, MASTERCARD, VISA, AMERICAN EXPRESS OR DISCOVER IS ACCEPTED.

I ASSUME RESPONSIBILITY FOR ALL CHARGES INCURRED FOR THE CARE OF THIS ANIMAL AND I UNDERSTAND

PAYMENT IS EXPECTED IN FULL AT THE TIME SERVICES ARE RENDERED.

SIGNATURE ______________________________________________________________________________ DATE _______________________

                                         (OWNER OR RESPONSIBLE PARTY)

THANK YOU FOR CHOOSING CROSSROADS FOR THE CARE OF YOUR PET!!!